Provider Demographics
NPI:1558636589
Name:JENNINGS, AMANDA MARIE (LMP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12015 NORTH EAST 8TH STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005
Mailing Address - Country:US
Mailing Address - Phone:425-451-4465
Mailing Address - Fax:425-462-4247
Practice Address - Street 1:12015 NE 8TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3141
Practice Address - Country:US
Practice Address - Phone:425-451-4465
Practice Address - Fax:425-462-4247
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60229213174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist